Podcast: Expert Answers to Questions About BPD
Jenn talks to Dr. Lois Choi-Kain about the intricacies of borderline personality disorder (BPD). Lois discusses signs and symptoms of BPD, explains the differences between treatment options, and answers audience questions about borderline personality disorder.
Lois W. Choi-Kain, MEd, MD, is the director of the Gunderson Personality Disorders Institute at McLean Hospital. She has also led a number of projects to increase access to care for borderline personality disorder (BPD) worldwide through teaching, supervision, and consultation. As an assistant professor of psychiatry at Harvard Medical School, Dr. Choi-Kain actively conducts research on BPD, focused on personality disorders, attachment, psychotherapy, and implementation and accessibility of care.
Jenn: Welcome to Mindful Things.
The Mindful Things podcast is brought to you by the Deconstructing Stigma team at McLean Hospital. You can help us change attitudes about mental health by visiting deconstructingstigma.org. Now on to the show.
Hi folks, good morning, good afternoon, good evening. Wherever you’re joining us from and whatever time you’re joining us, thank you so much for joining to learn all about borderline personality disorder.
And since that is such a long name for a condition, we’ll be referring to it as BPD throughout the conversation, so we don’t take up too much time with the name alone.
I’d like to introduce myself, I’m Jenn Kearney, and I’m a digital communications manager for McLean Hospital joined today by Dr. Lois Choi-Kain.
BPD can make a person feel like everything’s unstable, whether it’s variations in mood, behavior, relationships, or even thoughts, it can cause folks with the condition to be really quickly triggered. Sometimes it’s by things others might not react to or even notice.
And just because it’s a disorder that’s marked by tumultuousness doesn’t mean that those of us with it are doomed to live on a roller coaster of life. It can be treated effectively and it can allow people to live less turbulent lives if treated.
So over the next about 60 minutes, Dr. Lois Choi-Kain, and I are going to chat about signs and symptoms of BPD, methods to make the condition more manageable, some of the differences between treatment options that are out there and more.
So we have a lot to cover in a little amount of time, so I’m going to introduce her super briefly and we will jump right in. Dr. Lois Choi-Kain is the director of the Gunderson Personality Disorders Institute at McLean Hospital and her work spans both nationally and internationally to expand teaching efforts on BPD and evidence-based treatments.
So Lois, thank you so much for joining me for an hour and we’ve already got tons of questions, so I’m going to jump right in. Can you just talk very briefly about what BPD is, but more importantly, what BPD isn’t.
Lois: First of all, I want to say hello to everyone. I hope you’re well, wherever you are, and with whatever strains and stresses you’re managing, I really appreciate your presence here and your desire to learn.
We all need to spread the news about accurate knowledge regarding BPD so that we can empower people who suffer from the disorders, their family members and the clinicians who treat them.
So with that, I’m going to start with what is BPD. First and foremost, I want to impress upon all of you, whether you struggle with problems of BPD, love someone who does, or treat patients who have these problems, it is quite common.
BPD is something that occurs in about one to 3% of the general population, which makes it very prevalent also as well in clinical settings. So when we see patients in outpatient or inpatient psychiatric settings, about one in five to one in four of those patients will meet this diagnosis.
With that starting point, I want to say that this is relevant to all of us, that we all may know someone who struggles with these problems. And also, I want to say that BPD has symptoms that most human beings struggle with at some point in time.
Those with BPD have a more accumulated and pervasive sense of instability like Jennifer just said. As great starting point for understanding what BPD is, is understanding how personality works.
Our personalities define us, it has to do with who we are, that is how we understand ourselves, how we cope with our problems, how we see our identities and our self-image and how much confidence we have being in the world.
So that’s the side of personality that has to do with ourselves, but this, of course all influences how we deal with relationships, who we are and how we manage, define how we interact with others. That is how we understand them, how we relate to them and how we react to them when they’re there for us or disappointing us.
So we all actually have personalities, and I like to say, who doesn’t have a personality disorder at a specific time, maybe not meeting full criteria, but I think especially in these times where our lives have been enormously disrupted, causing us to redefine who we are and how we relate to each other.
We have all struggled with some symptoms of personality strain, and stress. Now that being said, there are many different types of personality disorders, and even among those types, it’s really hard to say that any one thing defines a person.
Personality disorders don’t define individuals, but its features are quite common prototypes for personalities that exist out there. Borderline personality disorder is thought to encompass the major symptoms of general personality dysfunctioning. So I’ll go over those first.
First and foremost, personality functioning has to do with how we regulate our moods. While it has a lot to do with how we manage moods, it is not a mood disorder.
And when I say how we manage our moods, I’m talking about how reactive and sensitive we are to various moods we experience, whether they’re positive or negative and how we express those moods.
So two symptom criteria of BPD have to do with its emotional instability, that is that moods are reactive to different types of stress. In the field of BPD treatments, we’ve thought about have these stressors in terms of emotional intensity and stress, interpersonal difficulties and stress, as well as stress more broadly.
So when we experience highs and lows of moods, we can be very reactive and unpredictable and managing those moods coherently and consistently is very difficult for people who have BPD.
In addition, people who have BPD have extreme states of anger, they encounter pervasive frustrations with how they feel they’re being understood, how they’re communicating to others and how others respond to them.
And because of how overwhelming this can be and how under supported patients can feel, this can actually be expressed in attacks of rage, which of course are very destructive to interpersonal relationships and a person’s sense of self.
Now, of course, these mood symptoms interact with how a person is in the context of their relationships. So the second realm of symptoms in BPD has to do with what we call interpersonal instability.
The first feature of BPD, the interpersonal feature of BPD is a frantic effort to avoid abandonment. Now, the way I understand this is that when you have such pervasive self-regulation difficulties, you just aren’t sure you can manage stressors that come your way, being very dependent and anxious about support that you have in your life is completely understandable.
So those who have this instability oftentimes are very vigilant about whether or not someone agrees with them, supports them, or is available to them. And oftentimes people with BPD will resort to extreme self-destructive measures to be reassured that people care.
Now, when I say this, this does not mean that I think they’re attention seeking or being manipulative, but it’s a basic state of attachment insecurity that those with BPD struggle with and express through this symptom of frantic efforts to avoid abandonment.
Now, because of this high level of dependency on others and low self confidence in one’s ability to cope, there is also an understandable degree of interpersonal instability, where relationships will fluctuate between being thought of all as all good or all bad, meaning destructive, punitive, or harmful.
So when those with personality disorders fluctuate between really heavily relying on someone in the kind of tone of feeling like they can do no harm and they are the answer to their many problems.
And then they face disappointments to which they react with frantic efforts of abandonment, then the relationship can plummet into a place of devaluation, discord, and then the result in the very abandonment that the patient fears.
Now, aside from emotional and interpersonal symptoms, there are behavioral instabilities. When people are struggling to manage their moods, they oftentimes have a very hard time coordinating their behaviors to get the help they need and express the distress they have.
Oftentimes those with BPD will react in impulsive ways because they are so uncontained, lost, deskilled and unsupported that they will resort to reckless behaviors that are self-damaging.
These behaviors can span a number of different realms one’s eating in the form of eating disorder behaviors, substance use and misuse, resulting in various severities of substance use disorders, aggression, that is aggression towards oneself, which I’ll talk a little bit more about and aggression towards others.
Spending, those with BPD we’ll sometimes go on spending sprees that are self-destructive when they’re very distressed, driving recklessly. You name it, whatever realm of activity there is, when somebody with BPD is feeling out of control, they’re really at risk for doing something that could be damaging and only add to the distress they have by accumulating the problems that they’re coping with.
We know through the research literature, that those with BPD are prone to only be stress reactive, but more prone to generate stress when they’re behavior in the form of self-harm and suicidality.
Now the majority of people with BPD will attempt suicide at some time, but the lethality of these attempts really varies. Oftentimes patients become very overwhelmed and distressed and see no way out and they will do things impulsively to find some relief. This must be taken seriously as a cry for help.
Others get more determined, that out of a state of hopelessness and despair that nothing can be fixed and they may resort to more serious and potentially dangerous attempts that could end their lives.
And our field in general needs to be better at detecting the differences between these two ends of the spectrum. In addition, people with borderline personality disorder will resort to self-harm, which has a very different function at times.
Self-harm or deliberate self-injury, that includes cutting, burning, headbanging, and other self-aggressive behaviors, often function to help a person calm down and regulate themselves.
There is some limited literature that have been done by European colleagues that have been published by European colleagues showing that self-harm actually reduces aversive tension for those who have BPD and also reinstates connectivity between the emotional seat of the brain and the executive functioning or the planning and strategizing parts of the brain.
So self-harm is really construed as a maladaptive, but proactive effort that people with BPD resort to, when they’re trying to regulate themselves. However, these behaviors actually escalate risk for actually completing suicide at some point in time.
Now, the last set of symptoms has to do with cognitions. Those with BPD are highly vulnerable to losing touch with reality in temporary ways under stress, they will often disconnect or become paranoid without an ability to reality test about their greatest fears, about themselves and others.
All of these instabilities together, contribute to a very diffuse and unstable sense of self. Once identity is informed by all these problems of personality functioning, and those with BPD oftentimes struggle with feeling like they’re bad, broken beyond repair, toxic or worthless.
So as you can see, the BPD diagnosis covers a wide domain of psychological tendencies and functioning. And so these problems can feel very overwhelming and unyielding for those with BPD, but what we can do is understand these symptoms better.
Now that I’ve said a little bit about what BPD is, I’ll talk a bit about what BPD isn’t. BPD is complexly comorbid with a number of different disorders. Because of this, there is often confusion about whether or not someone has BPD or a co-occurring disorder that oftentimes co-exists with BPD.
We are currently thinking about borderline personality disorder as a problem of resilience. If you have a lack of confidence, instability and managing yourself and being able to get the support and responses from others that you need, it is really going to diminish your ability to manage stress overall.
And because of this lack of resilience or diminished resilience, those with BPD are likely to develop other disorders in the category of mood disorders, anxiety disorders, substance use disorders, eating disorders, trauma-related disorders, and other personality disorders. While these things interact and overlap, they are quite distinct.
So BPD is not a mood disorder, although it commonly co-occurs with depression and sometimes with bipolar disorder. Bipolar disorder is one of the most common diagnoses that are given to people who have BPD by a physician before they receive the BPD diagnosis.
There’s a good reason for this, there are overlaps in the mood instabilities and other features that make them look quite similar in terms of symptom states, but furthermore, because of the wider availability of medications that help bipolar disorder and the relative under supply of psychotherapies that help borderline personality disorder.
Oftentimes clinicians are left in the lurch feeling like they’re opportunities to treat the problems the patient has maybe expanded by using a mood disorder diagnosis. That being said, it does not mean that that person does not have a mood disorder, but the co-occurrence of BPD can actually change the treatment plan.
And so the patient can get support and intervention for these broad areas of dysfunction that caused them to feel so overwhelmed and adding treatments for the co-occurring mood disorder is very important.
BPD is also sometimes thought of as a trauma-related disorder because the rates of early childhood abuse and trauma overall are high for those with BPD. Those with BPD who have had early childhood adversity of a variety of kinds, really struggle to develop the psychological capacities that make for more healthy personality functioning.
When someone is so overwhelmed with stress and has nobody to turn to, they will oftentimes really struggle to adapt to ways of coping and ways of receiving support that would most promote their mental health.
Now we have moved forward in the field in terms of our differentiation between BPD and PTSD, but what we come to is that it’s not constructive to argue that it’s one or the other, oftentimes these things co-exist.
And we can see that there are some overlaps, those who experienced trauma of any sort, they oftentimes really are sensitive to states of helplessness because they trigger memories of a time that was completely felt endangered, where they were helpless and powerless.
And oftentimes those who are traumatized in a variety of ways will avoid things that could cause them to feel helpless or escape through crisis. So whether you have BPD or a trauma-related disorder, these two models of thinking about one’s problems can be useful.
So BPD is oftentimes confused with these other disorder types, but it doesn’t mean that they don’t co-occur with those disorders. Lastly, I want to say what BPD isn’t, BPD isn’t a problem of a manipulative person or a character defect.
While personality disorders in general include symptoms that describe our personality states, these are not immutable as once thought, and they can transform through human growth and maturation.
Those who resort to extreme measures to get their needs met, are struggling to do better. They’re not aiming to harm or manipulate out of a choice to do otherwise.
So I think we need to hold that in mind, not that people are not manipulative, we can all be manipulative in different ways, but this is not necessarily too isolated to ones diagnosis of having a personality disorder.
Now, while there may be very good reasons for a person to feel this way about someone who has a personality disorder diagnosis, what we would really promote is a more constructive way of thinking about that, so that it brokers solutions rather than withdrawal and futility.
Jenn: I’m curious if individuals who have BPD often lack empathy, or do they find that they have a hard time caring about other people?
Lois: I think that people with borderline personality disorders and other personality disorders, do struggle with a stable capacity to understand themselves, vis-a-vis their social interactions with others.
And so when we talk about empathy, that is the understanding and concern for others that actually takes the coordination of a number different psychological functions, to be able to kind of maintain.
So those with BPD may kind of have an outcome of acting unempathically towards the others, but oftentimes they’re very flooded with confusion about what comes from oneself and one’s actions and what comes from another person’s attribution’s of you and attitudes towards you.
So, because people with BPD are oftentimes feeling a low sense of self-esteem, they oftentimes assume others don’t value them or are out to harm them and they react accordingly.
So there is a problem with the empathy in a way, but it’s because it’s kind of registered through this lens of reactivity, mistrust and a low self-confidence that one will get their needs met.
Jenn: Got it, so what is the average age of onset of BPD? And a follow up question would be how young can somebody be and be diagnosed with the condition?
Lois: Well, we all go through major transitions and personality functioning over time, and I think we can all see that adolescence through young adulthood is a very formative involved in the world in ways that define ourselves as well as engaging in independent relationships that start to fuel the way that we interact with others.
So it’s in that span of adolescence to young adulthood, that we first see symptoms of borderline personality disorder that has to do with this kind of mutation or transformation of personality.
Whenever we go through some sort of role transition, we may have some of these problems because we’re uncontained by a sense of self that’s consistent and a sense that others can understand and interact with us in predictable ways.
So for that reason, in this kind of highly transformative time, people will develop and start to express symptoms of personality disorder in their adolescence and young adulthood. And these personality features will kind of become more stable over time and start to define them.
And of course there’s patterns of interactions we have with those who have personality disorders that reinforce these tendencies. So I would say that this is something that starts to unfold at a critical period for people where a lot of mental illnesses start expressing themselves.
So it can be very confusing for patients, their families and the clinicians who treat them. Borderline personality disorder is now understood to be something that can be diagnosed much earlier.
There are reliable means for diagnosing personality disorders early, and we believe that intervening earlier, while personality functioning is still in development is really going to be more effective than waiting for a number of years for people to kind of get set in their patterns of behavior and interaction so that these personality features become more fully entrenched.
So we know through some studies, as some studies have been done in Europe where there are good registries of diagnoses among people who have encountered mental health services, that among those who have BPD, sometimes they have an average of three or more years before somebody tells them they have BPD.
So making that diagnostic disclosure, even when it’s just part of the differential diagnosis, meaning even when it’s just a kind of possibility in the clinician’s mind, is something that we really are trying to encourage so patients and their families can have the most opportunity possible to learn about the disorder and start managing its symptoms.
Jenn: Do you know if anybody has looked at the prevalence of BPD among people who have been adopted? And if yes, is there anything that you might be able to share about what they found?
Lois: Well, I actually don’t know the statistics on the rate of BPD amongst those who have been adopted, but those like any other group of those who have been adopted, have a variety of different experiences with that status and that aspect of their identity.
Some will have innate characteristics that interact with their personal situations. So that a feeling of not belonging, not being understood can be very common. And this becomes a seed of some of these difficulties regulating oneself, and then being able to be attached securely to others, it’s very understandable.
Oftentimes those who have been adopted have a kind of struggle with the notion of why that happened for them, and when they have these questions about do I belong and am I good enough to be loved or cared for in the way I need, those people may be more prone to feeling more desperate, more confused and more dysregulated in relationships so that they start to develop the very patterns that reinforce problems of BPD.
Jenn: How can providers help a person with BPD who might be in denial of their diagnosis? And if you have encountered this, what steps have you taken to address the scenario with a patient?
Lois: I think for any patient and any diagnosis, the clinicians involved, their responsibility is to deliver their best sense of what’s diagnostically going on for their patient, from their point of view, from their opinion, and explain it in a clear and accessible non-pejorative de-stigmatized way so that objectively, they can look at this together.
And then the patient can determine for themselves whether or not that diagnosis fits. The clinician can only do their best to provide their diagnostic impressions and explain them clearly and then the patient will decide to adopt them or not.
So I think what we would say to clinicians is that we encourage them to meet that standard of care and ethically disclose their professional opinion to give their patient autonomy and agency in determining what they’re going to do with their treatment plan.
And then there are these different ways that we can describe the problems of borderline personality disorder that we’ve learned from its evidence-based treatments that can put these symptoms into context so that the patient can understand better how it may or may not fit for them.
And then also constructive paths forward. So for example, dialectical behavioral therapy has explained that borderline personality disorder is a problem of emotional dysregulation.
And that oftentimes really resonates for patients that yes, I have problems managing my emotions, I’m highly sensitive to emotions, I get reactive.
I manage in ways that cause more stress rather than relieve stress, and then I have a hard time calming down. And I’ve grown up in a way that people don’t understand my emotional dysregulation and how difficult it is for me to manage. So then they actually don’t provide support and they invalidate me, or they expect things of me that I can’t deliver on.
So those who have emotional dysregulation and lack the support from their environment and skills to manage better, oftentimes will find it useful to work on ways of improving their behavioral management, improving their ability to focus and get into a place where they can define problems clearly and then manage them effectively.
So that’s one way of framing problems with BPD. Another that has arisen from mentalization-based treatment has to do with the idea that those with borderline personality disorder have problems of insecure and disorganized attachments.
That means that they are oftentimes very vulnerable to needing people, to be there for them and take care of them, but being highly fearful and reacting in ways that are confusing or destabilizing, that is disorganizing for that relationship.
And because of that instability, they develop inconsistent and unreliable ways of understanding what happens in social transactions. They can become overly certain about things or overly detached from realistic ways of reflecting on what’s going on for them when it comes to their relationships with others.
And then because of this instability of understanding social transactions is difficult for those people to then learn in social environments. They find it difficult to connect in places like some unity settings so that their development becomes quite limited and they get very stuck.
So when some people really relate to this idea that I don’t attach well, I generate a lot of hyperactivation of my attachment situations and then I can’t think through them clearly, and then I can’t find my way forward out of the problems I have in my life, they oftentimes will really relate to the idea that they have to kind of slow down and think about how they can manage their attachments more effectively.
To think more clearly about what’s going on for themselves and others vis-a-vis these interactions, and then be more open to learning from others and what points of view they offer, that are alternatives to they’re very negative and rigid points of view that they naturally have because of their borderline personality disorder.
And lastly, I’ll just name that some people will think of borderline personality disorder as a problem of interpersonal hypersensitivity. This is a more, is a similarly broad concept, like emotional dysregulation that we can all be sensitive to relationships.
And when you need someone intensely and you’re anxious about them leaving you, you can react in these very threatened ways that again, like we’ve said, can disrupt that relationship and make one feel lost, uncontained and out of control.
So managing one’s interpersonal hypersensitivity and one’s dependencies on figuring out ways to deal with them more predictably can be another relatable pathway for patients to think about their problems with BPD.
Because for some patients just thinking about the symptom, don’t provide a clear set of solutions for what they’re to do about their problems.
Jenn: Can you talk a little bit about the struggles regarding identity as well as security that’s associated with identity in folks who have BPD?
Lois: One idea in the world of BPD treatments is that those with BPD, struggle with something called splitting, they have very fragmented ways of thinking about themselves and others as all good or all bad, hence the criteria of unstable relationships, where they fluctuate between idealization and devaluation.
So this concept of splitting is really interwoven with the concept of having a poor sense of self. When you have a poorly developed identity and you don’t have like a central commander on board, it can feel like everything that happens to you is something that you have to react to. And it can kind of fluctuate from these extremes of good and bad.
So when you have these extremes in interpersonal functioning, that you can be very dependent and connected and feel very good about the relationship. And within a moment, it can all flip over into a very persecutory, punitive neglectful relationship.
You’re going to get confused about how worthy you are of anything and how much you can rely on others. So relationship stability and identity really go hand in hand.
How stable your relationships are, will fuel a more steady sense of self and a more steady sense of self may make you more understandable and predictable to others so that they can react to you in a way that’s more coherent that provides more validation so to speak.
A kind of recognition of who a person is and what they’re trying to convey in at any given time. So this is kind of a shorthand for how I would relate identity to interpersonal functioning.
Jenn: I know I had mentioned previously in the session that we would be talking about all the ways that you can treat BPD, so I want to address some of that before we run out of time because you’ve given us so much good information already, but I would be remiss to not talk about treatment options.
So first and foremost, when looking for a provider, what would I need to know to determine if the provider is using methods that would effectively diagnose BPD?
Lois: First of all, I would say this, those who have borderline personality disorder need support of many sorts. And while there are many evidence-based treatments that work for BPD, they don’t actually work for every single person who has BPD.
And the good news is that there’s options, the bad news is that the supply is very limited and those who need treatment, who want treatment and are motivated for care, oftentimes can’t find it.
So I want to say first and foremost, that if you have borderline personality disorder, finding a clinician, even if they don’t do an evidence-based treatment, but likes working with patients who have BPD, understands BPD and has a coherent way of providing care is someone that I think can do good work.
I’ve supervised a number of clinicians of a variety of orientations that are both specialized for BPD and just generalized to the broader psychiatric population. And I think someone who works consistently and understands the problems of borderline personality disorder can deliver good enough care.
And often times I think, it’s a tendency we have to wait for the gold standard and in the meantime, often suffer and struggle, so that problems become more unmanageable.
So that if that moment comes, if that treatment becomes available, which is often years for some of these wait-list, a person is more demoralized and more saddled with difficulty and despair then would best enable them to do any of these treatments.
So getting in any treatment with anyone who can work constructively with you, is one thing I would recommend.
While you can ask them, if they’ve been trained in any of these evidence-based approaches, you can also ask them what they know about them and what they use from them if they don’t practice dialectical behavioral therapy and mentalization-based treatment, transference-focused psychotherapy, or with psychiatric management, just to name a few approaches.
I’ve done a lot of work, just trying to simplify and clarify the core ideas and these approaches so that most professionals can understand these core concepts of how BPD works and use it as a framework that they can talk to patients about so that they can collaboratively understand the problems together and work on them using good, common sense and clinical judgment.
So the last thing I would say about that, sorry, is that patients really can empower themselves with seeking out more information like in this format, self-education or psychoeducation through publicly available resources, empowers patients to bring up the concerns that they know matter.
And patients have just as much an ability to guide care as clinicians do, and oftentimes clinicians will be open to hearing what the patient knows and what they think could work for them. And the clinician will have to discuss with the patient what they can and cannot do.
Jenn: First of all, never be sorry for encouraging people to be their own patient advocate. I am a huge believer in good free education, stuff like this is out there if you look for it. But I do know that you mentioned, you said good psychiatric management, right?
So can you talk a little bit about GPM, which a lot of clinicians know it as, but it’s practicality for treatment of BPD, because I know a lot of folks might not actually know that this is a treatment option.
Lois: Good psychiatric management is a treatment that was developed by John Gunderson’s vast, you know, kind of clinical expertise and empirical contributions to what we know now about borderline personality disorder, through his many research investigations, studying borderline personality disorder longitudinally.
He learned with his collaborators that borderline personality disorder is a condition that was thought to have a poor prognosis, but can improve naturalistically over time, even without specialized care.
The problem is this happens slowly during a very formative period in someone’s life, so that it really interferes with the kind of development those who don’t get derailed by BPD can experience.
So, you know what GPM really aims to do is to enhance the good clinical care that most mental health professionals already know how to deliver.
With specific knowledge about BPD, its symptoms, its core engines like interpersonal hypersensitivity, it’s longitudinal course, it’s comorbidities, it’s treatments, and that the importance of having the capacity to get a life and have corrective experiences outside of treatment.
Having experiences in the real world where you can see yourself as someone who contributes, as someone who’s part of a larger mission or community or effort can help build or solidify personality functioning like it does for all of us.
So good psychiatric management came into visibility because it was a comparison to dialectical behavioral therapy in a large trial, that was the first of its size to be done outside of the treatment developer’s lab.
And the investigator in that study, Shelley McMain, really wanted to have a comparison treatment that was also informed, structured, and employed by people who wanted to work with patients who had BPD.
And just by making those minor adjustments, even though GPM took a lot less time overall than DBT, the investigators found the outcomes were comparable. There were no statistically significant differences in the outcomes at the end of treatment and then at two years follow-up, that was a remarkable finding.
So that really propelled John Gunderson, in the last stage of his career to re-manualize what was called general psychiatric management in that study into good psychiatric management so that most clinicians could use it in their practice.
Now, how do you find clinicians who do GPM? The good news is that we found through training clinicians across the world is that those clinicians who have openness to working with BPD patients and have experience, tend to already know the things that GPM training teaches professionals.
What it does is for those clinicians who are less experienced or less clear about approach, is that it provides a more kind of coherent, instructive pathway for managing a variety of clinical dilemmas that we all get into, working with those who have BPD because of the behavioral, interpersonal and emotional instabilities that are involved in the diagnosis.
GPM really teaches clinicians to keep in mind that the clinical challenges that they face, involve the expectable symptoms of BPD.
Oftentimes those involved in the treatment process, whether it’s the patient, their family, or the clinician, they’ll oftentimes assume that the symptoms themselves are a sign of a bad patient, a bad doctor or bad treatment, or sometimes a bad family, but the truth is these symptoms are what the patient needs treatment for.
So having some non-reactivity, some clarity, some constructive ways of thinking and talking about BPD is really what GPM essentially rests on.
And with GPM, we really encourage people to use good, common sense and convey their opinion to patients, so that patients are empowered to advocate for themselves and set their own goals and decide what is, and what is not in the service of those goals.
Jenn: If GPM isn’t an option for somebody, what are other forms of treatment that someone with BPD can receive? And a piggyback question to this would be, do you know of any FDA approved medications to treat BPD?
Lois: Well, there are to date, no FDA approved medications to treat BPD. Last spring, the FDA actually invited a number of BPD experts and researchers to talk to them about how we could design studies to better investigate things that could help with BPD that were pharmacological.
So what I would say to begin with is that there are many medications that are found to relieve symptoms of BPD, but none of them are curative of the disorder themselves, so we consider those adjunctive.
But, you know, I have really mixed feelings about medications. On the one hand for some patients, they are incredibly important to stabilizing the patient in terms of the comorbid disorders they have like depression or anxiety or psychotic symptoms.
So they’re fundamental for symptom management and without the medication, some patients can’t actually engage in treatment fully. So I would encourage judicious use of medications to enhance the patient’s ability to participate in treatment.
The benefits of GPM is that it’s one of the treatment modalities that are designed for BPD that integrates a set of guidelines for prescribing medications.
Now, if people cannot find a GPM trained clinician, which is really common, it is very hard to disseminate any of these treatments into the kind of population of clinicians that are on the frontline.
There’s a couple of things that I would suggest because a lot of people have contacted me about referrals, there are just way too many people in need to be able to address all those requests.
But the good news is good psychiatric management training is currently online at a low cost. It’s highly subsidized right now, so it’s $25 for a full day of training that if your clinician is interested, they can do that until July of 2022 and receive the kind of basic training that really helps clinicians to have more hope in treating those with BPD and also confidence in their ability to be helpful.
Otherwise, I think that, like I’ve said, if you cannot find another evidence-based treatment, really trying to advocate for yourself through psychoeducation is really an important pathway that’s widely available through online resources and organization resources.
So there are many organizations that support those with BPD, as well as their families, the National Education Alliance for BPD is one of the major ones alongside with Emotions Matter, TARA 4 BPD, there are many that I think Jennifer, you all make available for everybody.
Also, I’ve been very impressed by working with collaborators in Australia. Their public health system is very invested in proliferating information about BPD and training for its clinicians, so there’s a lot of relevant resources online from those Australian organizations.
So I would really encourage checking those out as well, but we know that psychoeducation in and of itself can improve symptoms of BPD.
And one of the ideas we have about this is just having a coherent idea about what BPD is, can help people have more of a kind of sense of control over how they’re going to manage and respond to it rather than leaving something so ill-defined and prone to negative attributions, which a person with BPD as we’ve discussed is just vulnerable to.
So we know through research studies of psychoeducation that the psychoeducation about BPD, even if it’s brief or online, can reduce BPD symptoms in a short amount of time. So that in and of itself, if you can’t find other forms of treatment, doing things like what you’re doing right now is oftentimes actually helpful and empowering.
Jenn: So how quickly can treatment start to significantly reduce the symptoms of BPD or is it really person-specific and case-specific?
Lois: Well, the interesting thing about this question is that while BPD is a very challenging disorder to live with and treat, there is increasing evidence that actually a major consistent predictor of change in the treatment of BPD is having severe BPD at the start of treatment.
So even though those with BPD may have a very serious level of acuity and dysregulation and instability at the start of treatment, getting involved in a variety of coherent, consistent, structured ways of addressing the problems of BPD have immediate effects.
It seems like across studies, some of the major effects in symptom reduction, especially in the realms of impulsivity happen right away.
In our own research study, having to do with residential treatment that we have at McLean, we find that there is a significant symptom reduction in the first five weeks, containment, a kind of consistent environment, structure, separation from self-destructive means or de-stabilizing relationships can actually do a lot for a patient.
Longitudinal studies also show that such situational changes can breed remission in as quickly as six months.
So really understanding the context in which you’re having your difficulties, the things that cause you to be symptomatic, and then reducing those in a way that’s realistic and sustainable is another thing that people can do in the absence of specialized care.
Jenn: We had a parent write in saying that their daughter has been working with a DBT therapist for nearly 10 years.
She exercises, she does yoga and she watches her diet, but she sometimes gets frustrated by all the work that she feels is necessary for her to quote, just feel normal, and feels like she’ll never get better.
And if she falls off this kind of schedule, she’s overwhelmed by the amount of work that it’s necessary for her to get back on track. As a parent, it’s difficult to watch a child struggle. Do you have any suggestions on how to be a supportive parent when dealing with this?
Lois: I think already you’re being a supportive parent by recognizing how challenging it is not only to recover, but to stay healthy.
So these evidence-based treatments we know, work for those with BPD are a lot of hard work and that’s what makes them very specialized so that whatever the treatment modality, the patient has a number of demands that they have to be responsible for, not only to have symptom reduction, but to continue to function.
And this involves the patient having to suppress their urges or their primary impulses of how they want to manage things or react to things in favor of more constructive means.
Now, for all of us, this is hard work, we’ve all dealt with a lot of urges and ineffective behaviors over time, especially in stressful times like these and repressing those urges and trying to do something constructive is hard for everyone.
But imagine doing that across a number of domains of your psychological functioning across your mood, your behavior, your thoughts, your relationships, and having to do that full time is quite exhausting.
Now the good news is once you get consistent with it, it begins to define you, it becomes incorporated into who you are and over time it can become second nature.
So I would ask you not to give up hope, but I think also recognize that progress is hard work to both achieve and sustain and validating that for your loved one is the best you can do.
Jenn: What would you consider to be effective or ineffective things that the partner of a person with BPD can do to support them while they’re in treatment?
Lois: I think that the most effective thing that a partner can do to promote someone’s wellbeing, who has BPD is to really learn about the disorder and think not just about what the person needs, but what they need to respond to their partner in a way that promotes their partner’s growth.
One of the difficulties of treating BPD or loving someone who has BPD is that the symptoms themselves tend to elicit responses from others that over time can disempower the patient with BPD.
So, because they’re so vulnerable and are so insecure in their own capacity to manage their various stressors and problems, others who are concerned and well-meaning tend to take over.
But that actually ,over time, can deplete that person’s self-confidence, there are opportunities to master and cope more effectively, and then ultimately build more self-confidence and a positive sense of self.
So really trying to think about your own behaviors, tendencies ways of supporting your loved one and thinking about ways to improve that over time, according to where your partner is with their treatment and their own recovery, I think is something that can be very constructive.
One last resource is that Family Connections is available for family members or significant others of those who have BPD, and that is a training and support group that’s run by other family members and partners that conveys skills and knowledge that can help you do this in a clear and effective way.
Jenn: Couple more questions for you, ‘cause I know we are quickly running out of time.
There seem to be a lot of support groups that are available for young women and adult women who are struggling with BPD. Do you know of any types of support that are available for men with BPD?
Lois: That is a good question, I actually do not know the answer to that, but I think that’s something that we should probably look into and make available afterwards.
But that’s a really important consideration because I think that we are more aware that borderline personality disorder is a very heterogeneous disorder and different people experience the symptoms in different ways, at different stages of life, at various stages of illness.
And they need different kinds of support or different communities over the period of all of that. So we’ll find out the answer to that and provide it online.
Jenn: And one more question for you, which I know we were inundated with questions, so I can’t thank you enough for already covering so much information, but is BPD a permanent diagnosis or is it something that can be brought on by our environment?
Lois: I think it can be both. There are situations in which people who would otherwise be steady, endure overwhelming degrees of adversity and distress so that their personalities become quite dysregulated and dysfunctional, and then they meet criteria for BPD for a stretch of their lives.
There is a distinct population of patients who will have single episodes or brief times of BPD that will with the right resources recover or even with the right life circumstances, remit.
Now there are others who have circumstances that make it very hard for them to recover, or they won’t have access to treatment or their constellation of problems will be just so such that it’s more challenging to focus on the changes that they need consistently over time.
Another factor here is that just because a patient remits from their symptoms, it doesn’t mean they recover enough to participate in life. That allows them to access, to feeling like life is meaningful and has opportunities that give them positive self-esteem and keep their mood and anxiety levels manageable.
So what we need to do better in the world of treatments for BPD is not just pay attention to the recovery from the disorder, like the parents said, all the work that has to be done.
Whether during doing DBT or some other treatment to get well enough, then to kind of pursue meaning in life and do things outside of self-care and symptom management to build your life forward, to develop meaningful relationships, to be a person that matters in the world.
That actually is something that’s not as consistently found for people who have BPD, and part of it is that we need to develop treatments that focus on that phase of recovery more effectively, so that those with BPD can not only remit from their disorder, but then go on to lead stable, meaningful lives. We all need that.
Jenn: And I think that that is the best note that we can end this conversation on. So, Dr. Choi-Kain, thank you so much for taking an hour out of your very busy schedule to chat with me about all things BPD.
And folks, today, we have talked a lot about training opportunities for BPD. If you are interested in getting more information on Dr. Choi-Kain’s trainings, you can go to mcleancme.org, that’s M-C-L-E-A-N-C-M-E.org.
We will also include a link to that in our resources, but until next time, thank you very much, Lois, this was exceptional and thank you to everybody tuning in.
This concludes the session, so be nice to one another, but most importantly, be nice to yourself. Thank you again, take care.
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Don’t forget, mental health is everyone’s responsibility. If you or a loved one are in crisis, the Samaritans are available 24 hours a day at 877.870.4673. Again, that’s 877.870.4673.
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The McLean Hospital podcast Mindful Things is intended to provide general information and to help listeners learn about mental health, educational opportunities, and research initiatives. This podcast is not an attempt to practice medicine or to provide specific medical advice.
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